Drug-induced hemichorea

Acute Hemichorea in an Elderly Patient With Positive Anti-centromere Antibodies and Lung Tumor

Though rare, autoimmune paraneoplastic and non-paraneoplastic chorea can be leading causes of adult-onset acute/subacute chorea. Here, we report a case of acute-onset chorea with suspected autoimmune-mediated mechanisms in a 79-year-old female who exhibited acute-onset choreiform movements on the right side of her body. She tested positive for anti-centromere antibodies (ACAs) without displaying symptoms of scleroderma. Blood sugar levels, genetic testing for Huntington's disease, and an antibody panel related to paraneoplastic neurological syndrome were unremarkable. Brain magnetic resonance imaging revealed no significant abnormalities. Computed tomography (CT) identified an irregularly shaped nodule in the middle lobe of the right lung. An 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET)-CT scan showed an accumulation of radioactivity in the nodule and slight hypermetabolism in the striatum of both hemispheres. Her choreiform movements almost disappeared with a low dose of tiapride alone, without the need for anti-tumor therapy or immunotherapy. In cases of adult-onset acute/subacute chorea, investigating neoplasms and autoimmune diseases as underlying conditions is recommended. Tiapride, due to its good tolerability, is a valuable symptomatic therapy for elderly patients presenting with chorea, even in cases driven by autoimmune mechanisms.

Diagnostic Uncertainties: Chorea

Chorea is a hyperkinetic movement disorder with a multitude of potential etiologies, both acquired and inherited. Although the differential diagnosis for new-onset chorea is extensive, there are often clues in the history, exam, and basic testing that can help to narrow the options. Evaluation for treatable or reversible causes should take priority, as rapid diagnosis can lead to more favorable outcomes. While Huntington's disease is most common genetic cause of chorea, multiple phenocopies also exist and should be considered if Huntington gene testing is negative. The decision of what additional genetic testing to pursue should be based on both clinical and epidemiological factors. The following review provides an overview of the many possible etiologies as well as a practical approach for a patient presenting with new-onset chorea.

Occurrence of involuntary movements after prolonged misuse of zolpidem: a case report

Zolpidem is a non-benzodiazepine agent used for short-term treatment of insomnia. Several cases of dependence and withdrawal from zolpidem are reported in the literature. Furthermore, involuntary movements after prolonged zolpidem misuse have been described. In this case report, a 69-year-old Italian woman with no history of diagnosed psychiatric or neurologic diseases developed uncontrolled movements and a depressive-anxious syndrome after twelve-year zolpidem misuse. The underlying mechanisms of involuntary movements occurring after long-term zolpidem intake are unknown; yet, we suggest that zolpidem might induce an increase in dopamine release through inhibition of gamma-aminobutyric acid neurons tonically suppressing dopamine cells. Future studies on the occurrence of persistent disorders after long-term benzodiazepine or Z-drug abuse are needed and clinicians should pay attention to the risk of tardive syndromes related to zolpidem misuse, especially in the case of long-term intake of over-therapeutic dosages.

Sertraline-induced Hemichorea

Background

Hemichorea–hemiballism is a syndrome secondary to different etiologies. Drug-induced hemichorea is a rare syndrome related to selective serotonin reuptake inhibitors. To the best of our knowledge, no previous cases of hemichorea associated with sertraline have been reported.

Case Report

A 65-year-old female noticed hemichorea 1 week after initiation of sertraline. After extensive investigations, other causes of hemichorea were excluded. Hemichorea remitted after sertraline withdrawal.

Discussion

In our patient, temporal association and the negative clinical assessment supported a diagnosis of likely drug-induced involuntary movement. We hypothesized that enhanced serotonergic transmission in the ventral tegmental area or nigrostriatum may be involved in sertraline-induced hemichorea.

Statistical Analysis of the Effectiveness of Seawalls and Coastal Forests in Mitigating Tsunami Impacts in Iwate and Miyagi Prefectures

The Pacific coast of the Tohoku region of Japan experiences repeated tsunamis, with the most recent events having occurred in 1896, 1933, 1960, and 2011. These events have caused large loss of life and damage throughout the coastal region. There is uncertainty about the degree to which seawalls reduce deaths and building damage during tsunamis in Japan. On the one hand they provide physical protection against tsunamis as long as they are not overtopped and do not fail. On the other hand, the presence of a seawall may induce a false sense of security, encouraging additional development behind the seawall and reducing evacuation rates during an event. We analyze municipality-level and sub-municipality-level data on the impacts of the 1896, 1933, 1960, and 2011 tsunamis, finding that seawalls larger than 5 m in height generally have served a protective role in these past events, reducing both death rates and the damage rates of residential buildings. However, seawalls smaller than 5 m in height appear to have encouraged development in vulnerable areas and exacerbated damage. We also find that the extent of flooding is a critical factor in estimating both death rates and building damage rates, suggesting that additional measures, such as multiple lines of defense and elevating topography, may have significant benefits in reducing the impacts of tsunamis. Moreover, the area of coastal forests was found to be inversely related to death and destruction rates, indicating that forests either mitigated the impacts of these tsunamis, or displaced development that would otherwise have been damaged.